Advice on HRT

[EastCoast]

First post. Have read thru some great resources here. Looking to contribute my story to hopefully gain some feedback (...and potentially help some guys who may be in similar shoes as mine.)

Current
Age:32
Height: 6'0"
Weight: 172lbs


Once I hit my 30s, I started noticing metabolism slowing down. Increased body fat. Low energy. Less mental sharpness. Libido down a bit.
My weight had jumped up to close to 190lbs; I was the epitome of "skinnyfat." Started snoring at night time; had to wake up several times at night to urinate. Woke up fatigued. I felt I was headed towards Metabolic Syndrome (if not already suffering from it.) I decided to get my ass in gear; start eating better (researched things like Paleo/Primal diets, intermittent fasting), working out more/getting in better shape, attempting to sleep better. Overall I wanted to improve my quality of life, which was slipping considerably.

In my research to optimize all these facets of my life, I came across HRT and TRT. I started reading voraciously; consuming knowledge from forums, articles, blogs, medical journals, youtube videos ... anything I could get my virtual hands on.

I read a ton about TRT and decided that even if I don't start TRT now; let me see where my blood levels are and let me try to dial in and optimize my overall well being.


Summer of 2013
I was 6 ft tall; weighing close to 190lbs; with a 36inch waist; ~25% bodyfat. Considerable amount of belly, back, flank, thigh fat. Snoring at night (found out it was due to enlarged tonsils.) Started lifting heavy compound lifts; at first did the Starting Strength program focusing on Squats, Deadlifts, Bench, Overhead Press, Pullups, etc.. Then I figured that I needed to join a real gym (i.e. one with real power racks, not just Smith machines) and hire a personal trainer to dial in my form plus provide a financial motivation for me to keep busting it at the gym.

I started some supplementation as well. Vit D 5000 units daily, Zinc 50mg daily, Creatine 5g daily.
Tried to fix my diet as well. Dabbled in intermittent fasting; attempted to limit carbs; added in some protein shakes. But I did NOT monitor my calorie intake systematically.

Libido was down a bit. After a single session with a lady friend; it was rare if I could ever get going for a second go-round in the same night.
Overall life stress wasn't too bad at the time either.

As mentioned, I decided to get labs done to see if low T could be contributing to some of my slip in quality of life and/or if TRT could provide a bump.
[I'll provide a lab flowsheet below]

My total T at this time was around 500, estradiol in the high 30s, cortisol and DHEA were very high, thyroid not exactly optimal, and glucose metabolism also needed some work.

While my total T was low, I decided I was going to try to fix some of these ancillary issues prior to committing to TRT.


Dec 2013

Weight dropped to mid 170s (from 190lbs). Body fat % reduced to the high teens (from 25%).
Had tonsillectomy to improve snoring; improved sleep hygiene.
Started using MyDailyFitnessPal App to track calorie intake.
Continued Vit D, K2, B12, E, Selenium, ZMA supps.

Had next lab panel drawn.
Again Total T around 500. Estradiol improved to 25 (from 37). IGF-1 actually went up (maybe due to heavy lifting?) Cortisol/DHEA still elevated. Some improvement in thyroid (minor). Little improvement in glucose metabolism.

I figured I was making some minor improvements thanks to lifestyle/supp changes; so again let me continue down this path and not commit to TRT just yet.


Feb 2014

6'0" 172lbs bodyfat % still in high teens.

Sleep improved to excellent since tonsils out.
Started working with a nutritionist to really dial in diet for both training and non-training days.
Started cooking >90% meals at home. All organic, GMO-free, free-range, grass-fed, etc. products.
Stuck with personal trainer; 4 days per week; heavy compound lifts.

Again, Total T did NOT budge (still around 500). Estradiol leveled off in the 20s. Adrenal labs improved. Glucose metabolic labs about the same. Thyroid function improved a bit.

-----



I've included a flowsheet of my lab progress to date.
In search of wanting to dial myself in completely and fully optimize my well-being/health/quality of life, I am again considering taking the plunge into TRT.

I could also continue on my current path with the lifestyle changes I've made.
Possibly add in others that you guys might suggest...
and then again wait & see ... and hope for some improvement in another couple of months.

Or I could come to the realization that perhaps I have maxed out my natural potential (while making some improvements in thyroid, adrenal, other functions) ... and that maybe now I can honestly and smartly consider TRT; having tried non-hormonal methods thus far.


Interested to hear feedback.

 

[Vettester Chris]

EC, thank you for joining, and a BIG thank you for providing such an excellent, detailed post!! There is a lot of information, so it should encourage much conversation from many angles.

Before I get too far, can you please give me the unit of measurements for your Free T3, Total T3 and Reverse T3? Has your physician discussed his opinions on your TgAb antibody assay, which is speaking loud and clear. The concern for Hashis (IMO) is evident, as this lab shows your immune system is attacking your thyroglobulin, which is at the protein level (TPO being peroxidase enzyme). Either way, let's see what RT3 ratio is with FT3 and/or TT3 and start with that.

There's kind of an odd deviation going with your platelets; your last lab definitely on the low end. Again, I'd be curious on what the doctor's perspective is with that subject?

On the cortisol, it's really hard to make heads or tails with a basic serum test. Especially not knowing the time of day. As I suggest for everyone, the gold standard with many leading physicians is the 4x Saliva Panel. Getting a circadian pattern from early in the morning (at it's highest) to late night (lowest) is going to reflect how your adrenals are truly performing throughout the entire day. You provided us with a ton of information already, but hoping you will research this one a little further.

Although, your testosterone serum might not be exactly where you would prefer, it's not completely terrible sitting in the 500ng/dl zone either. Your HPTA appears to be producing sufficient amounts of LH & FSH, so IMO that's not the defining factor with your issues. Maybe, ideally you would like to see your serum up a bit, but again, I don't think that's the magic fix with the issues you're experiencing.

Let me know on those thyroid units of measurements, and we'll chat some more. I'll post more about the thyroid levels of T4 compared to T3 on a future post. Thanks again for signing up and sharing!

 

[EastCoast]

Thanks for the reply.
I've been able to surf around some more and find great resources here.
You guys have done a great job.

please give me the unit of measurements for your Free T3, Total T3 and Reverse T3? ... Either way, let's see what RT3 ratio is with FT3 and/or TT3 and start with that.

Free T3: pg/mL
Total T3: ng/dL
Reverse T3: ng/dL

Note: I did not have Total T3 or Reverse T3 tested on most recent labs.
However, my TSH did improve.

Has your physician discussed his opinions on your TgAb antibody assay, which is speaking loud and clear. The concern for Hashis (IMO) is evident, as this lab shows your immune system is attacking your thyroglobulin, which is at the protein level (TPO being peroxidase enzyme).

Yeah its odd. The way the Thyroid labs were ordered this most recent time around were as a "thyroid panel"; as opposed to individually selected labs.
The TgAb test is apparently a routine inclusion on that panel.

Not quite sure what an elevation in TgAb, coupled with an absence of other thyroid lab derangements, as well as lack of clear evidence of typical thyroid related symptoms actually means.

There's kind of an odd deviation going with your platelets; your last lab definitely on the low end.

Yeah, the middle value from Dec 2013 is likely the outlier. I have had low platelets all my life; since I was young.
I recall seeing a hematologist as a teenager; but he didn't think anything needed to be done at the time.
Of note, I don't bleed or bruise easily; no frequent bloody gums while brushing teeth or anything either.

On the cortisol, it's really hard to make heads or tails with a basic serum test. Especially not knowing the time of day.

All labs were drawn at the lab first thing in the morning; prior to 9am.
Pretty much right around the time where you would expect Cortisol to be peaking as you alluded to.

Like you also noted; this was a one-time early morning serum test.
This was not a 4x saliva test.
Nor was this a 24-hour urinary cortisol collection.

Regardless, I was quite happy to see the adrenal labs normalize on the most recent set of labs as I was seriously contemplating possibly getting a CT scan to rule out anything like an adrenal adenoma, etc..

If I had to attribute the improvement to something, I'd say the most likely explanation would be the improved sleep I've experienced ever since having the tonsillectomy in Nov 2013.

Although, your testosterone serum might not be exactly where you would prefer, it's not completely terrible sitting in the 500ng/dl zone either.

Yeah I agree that my total T level is not terrible. From my research, I believe it is below average for my demographic.
As noted above in the OP, I've been hitting the gym hard and really cleaned up my diet in hopes of optimizing quality of life.
It has been frustrating not seeing the T rise at all and thereby not seeing more dramatic results in the gym and in between the sheets either.

My main goal is to maximize my quality of life...
But I obviously don't want to sacrifice long-term health but rushing into any treatments prematurely/unnecessarily.

I want to be firing on all cylinders.
But also want to make sure I do all my due diligence prior to committing to any long term treatments.

Your HPTA appears to be producing sufficient amounts of LH & FSH, so IMO that's not the defining factor with your issues.

I noticed that as well.
I had previously mulled the idea of possibly starting with sole hCG therapy. However, as the trends of my labs show ... my pituitary was actually able to increase both LH and FSH in response to the changes I made in diet, exercise, sleep, etc.. Despite this increase in LH and FSH, there was no commensurate rise in T.

Therefore, I can't really see sole hCG therapy being the best course of action (if I decide to move forward with HRT.)
The best course would probably be going straight to T therapy ... and not mucking around with any sort of "re-start" or anything like that.

 

[Nelson Vergel]

Eastcoast

Man, you are a detailed guy! I love that. Congrats on taking charge of your health.

I am glad Chris was able to provide his comments.

I am a bit confused, though. Those lab results are a year old and you say very little about how you feel now (sex drive,stamina, erection quality, mental focus/coping).

 

[EastCoast]

Those lab results are a year old and you say very little about how you feel now (sex drive,stamina, erection quality, mental focus/coping).

I may have made a typo on dates.
First set of labs was from Sept 2013.
2nd from Dec 2013.
3rd (and most recent) from Feb 2014.


Symptoms

Sex Drive: Has not really changed since I started tracking labs/making lifestyle changes. I am usually good to go for one go-round but rare is the occasion that I can go for another round between the sheets until perhaps the next morning.

Erection Quality: Never did, nor do I currently, have too much difficulty maintaining an erection. I'd say libido and drive are more of the issue. For what its worth, I'm rarely if ever 'choking my own chicken.' Maybe once a month?

Mental Focus: Has dropped off since I hit 30. Have noticed a decrease in sharpness and motivation to take on new projects/tasks. I am still pretty high functioning at work; but ambition has just not been there.

Stamina: Physical stamina has been poor. This could definitely be related to having let myself get out of shape entering my 30s. Its marginally improved since I started working with a personal trainer and doing routine compound heavy lifting the past 8-9 months. That being said, I am just not seeing the muscle development I would have expected with the consistency with which I have been hitting the gym and focus on ensuring adequate protein intake/proper sleep.

 

[Vettester Chris]

EC, apologies for the delay. Thanks again for such thoroughness with your posting.

OK, I'm basing some of my thoughts on the December labs, since your most recent ones don't have the Reverse T3. With RT3 we are looking for healthy ratios, based in comparison to your T3; either Total or Free T3. STTM notes FT3 should be 20:1 or better in comparison to RT3. IMO, 20:1 is even a little conservative, but that's just my take ... Your FT3/RT3 Ratio is 16, which is indicating that RT3 conversion from T4 is a little higher than what you would want.

There's several factors that were going on at that time, which could be contributing to this. Your Iron Serum was a little on the low side (IMO), and high levels of cortisol can be a factor, which was evident at least by the presented serum lab. Again, it would have been more ideal to see a 24 hour circadian profile on your cortisol to really get the gist of it, but maybe next time you can broach that. Like you stated, some of those areas on your recent labs have improved, and you notice in similar fashion that your FT3 has climbed up, thus effecting the feedback loop with your pituitary and the TSH it produces. I would suspect if you had also ordered a RT3 lab, the result probably dropped several points, which in turn probably helped TT3 and FT3 activity to be more productive. That's all speculation on my part, but I'll put $5 bucks on it that I'm not too far off the path on this.

Just to tap on actual thyroid level amounts ... I support many in the medical community that believe optimal levels of FT4 and FT3 will be at 50% to 80% of their respective range values. On your December labs, your FT4 was 43% and FT3 was at 29%. Again, the RT3 level makes a little more sense why FT3 was much lower then, as compared to your recent labs. FT3 is now a little over the 50% mark, but FT4 is still a little low at 49%.

Regardless of anything I mention to you, I think it's imperative that you do some additional research on your Tg antibody lab, and possibly review it with another physician (if needed) to help you get to the bottom of it. My suspicion is Hashis at the protein level of the thyroid. If it is, it can be dealt with, managed, and still medicate with NDT medications if needed. Definitely don't just let it go, I think it should be addressed.

If it is Hashis, the attacks can come and go, and you will get bouts where you feel 'hyper' like, then periods where it goes 'hypo'. What's the best route for you? Good question. That's where you need to really align with a physician that can factor these variables, and other things that can help him/her to get you where you need to be.